Ailing Hospital's Progress Is Lesson for King/Drew

WASHINGTON — Greater Southeast Community Hospital in Washington D.C. had been stripped of its national accreditation, dropped by medical insurance companies and was being investigated for six "preventable" patient deaths between 2002 and 2003.

But over the last year, hospital administrators have been working to turn the medical center around.

They canceled vacations, demanded that patients get their medicine on time, even made sure fire extinguishers were working properly. During this period, 20% of the medical staff left or were fired.

The changes at Southeast were spearheaded by a group of outside medical consultants. One of them is now part of the team attempting to fix Martin Luther King Jr./Drew Medical Center, the troubled Los Angeles County hospital that has seen a series of patient care lapses that led to several patient deaths and threatens its accreditation and federal funding.

The experiences of Southeast — the progress that has been made, but also the serious problems that remain after a year of outside management — offer lessons to county officials as they struggle to reform King/Drew.

"In looking at the two institutions, I see huge numbers of similarities between them," said Glenn Krasker, the consultant at Southeast who is now at King/Drew.

Krasker came to Southeast as a medical detective of sorts, trying to determine what was going wrong. He found, for example, that the system for matching blood types to patients was faulty. Three patients had died at the hospital because they had received the wrong blood type. Nurses, Krasker concluded, had incorrectly labeled patients' blood samples, prompting him to institute standardized rules.

"What I found at Greater Southeast — and what appears to be a problem at King Drew — is that essential safe practices of healthcare were generally lacking," he said.

Both hospitals were founded in predominantly black neighborhoods, where many residents feel their healthcare needs have long been neglected. Both have struggled to provide proper care to the streams of patients that sometimes overwhelm the facilities.

Southeast and King/Drew are also intensely political institutions, serving as powerful symbols of the community.

"There's a conviction that the healthcare needs of black people are being ignored and that these hospitals are the only institutions that can address them," said Ivan Walks, former Washington D.C. health director who worked on Southeast. "There's a lot of distrust because of historical issues."

There are also differences: King/Drew is a public hospital, while Southeast is private, which made it easier to force out employees. Southeast is also larger, with 450 available beds, compared with 233 at King/Drew.

A year into the Southeast reform effort, serious challenges remain, including repairing a tattered reputation that has hindered it from recruiting new doctors and admitting enough patients to fill its beds. Currently, the hospital has fewer than 150 patients.

But there are some signs of progress: The hospital regained its accreditation, and the medical lapses appear to have declined.

Two years ago, Southeast found itself at the crossroads where King/Drew now stands.

Washington D.C. officials were pushing to close Southeast because city health administrators believed that problems there "continue to jeopardize patient welfare," internal documents show.

Hospital inspectors reported six questionable patient deaths at Southeast, including two infants, in 2002 and 2003. Two patients died because of mismatched blood transfusions. Another man who arrived at the emergency room with chest pain wasn't examined for 10 hours. He later died.

In November 2002, the FBI raided the headquarters of the hospital's parent company, Arizona-based Doctors Community HealthCare. Two days later, the company filed for bankruptcy protection.

Within weeks, agencies that provided security guards, nurses and some emergency room physicians stopped supplying personnel to the hospital. Although 20 doctors declared they would continue to work despite not being paid on time, ambulances were diverted to other medical centers because of staffing shortages. About 40% of the doctors left.

The patient load, which had been 250 in early 2002, dropped to 130 by the end of that November. By Christmas of that year, the hospital had laid off 78 of its 1,250 employees.

Despite problems, some community leaders were outraged that city officials were recommending the hospital's closure so soon after the public hospital in the area — Washington D.C. General Hospital — was closed.

Walks said some of the attacks were surprisingly personal.

"There were people telling me that I hated black people," said Walks, who is African American.

It was into this emotionally charged situation that Southeast hired Joan G. Phillips, Krasker and a group of consultants from Cambio Health Solutions.

"I came in on Wednesday, and by Friday, there was this letter that the [city] Department of Health wanted to close the hospital because of the six deaths," Phillips said.

Phillips, who now heads the hospital, determined that Southeast's staff had lost sight of standard hospital protocols, such as maintaining the flow of patients through the emergency room into other wards.

"I found that patients were staying down there for three or four days sometimes," she said. "They weren't diagnosed and placed in other wards, so when other emergency patients came in, we didn't always have beds for them."

Phillips found that logjams in the emergency room left doctors and nurses there overtaxed and other units underutilized.

So she enforced the use of patient flowcharts and checked the emergency room daily to make sure that patients didn't linger longer than necessary.

While Phillips focused on the administration of the hospital, Krasker focused on medical protocols. For example, Krasker found that patients weren't regularly checked by nurses.

"After they're given medication, how often should we check their vital signs? Every 20 minutes or 40 minutes? And once we settle on that, we have to create a paper trail and a monitoring system to make sure that they're doing it," Krasker said. "Now we're talking about managerial oversight. Accountability."

Krasker also cited fire sprinklers that didn't work. Fire safety was among the deficiencies cited by the Joint Commission on Accreditation of Healthcare Organizations when it stripped away its accreditation from Southeast.

"When you find a fire sprinkler head that's not working, you ask: 'Why is this not fixed? Who is supposed to fix it? Who is making sure that the person in charge of fixing it does so?' It's all about putting in place a managerial infrastructure," he said.

Krasker, 43, has worked in healthcare administration for 20 years and has worked for the Joint Commission on Accreditation.

In that post, he developed so-called "sentinel event" protocols, which require that hospitals identify breakdowns in patient care and conduct analyses to determine root causes for problems. Once an error is identified and its cause determined, safeguard systems are put in place to make sure such problems do not occur again.

With health inspectors visiting the hospital on a weekly basis, the Southeast consultants canceled all vacations, imposed six-day workweeks for supervisors and organized daily sessions to educate the staff about the new standards — and to crack down on those who weren't following them.

During this reform period, so many staffers left that Phillips is now attempting to replenish the hospital staff.

"There was no respect for the hospital, and I needed to set a new tone," she said.

Phillips discovered that some staff members had been abusing overtime, others had been clocking in and then leaving for jobs at other hospitals.

Another problem was that the number of outside contract nurses had soared as the hospital's financial state worsened. At the height of Southeast's problems, 70% of the emergency room staff were employees of private agencies, Krasker said.

Some agency workers, said Phillips, felt more accountable to their outside employers than to Southeast's staff.

"Agency nurses were holding us hostage because we were so dependent on them…. They wanted double time and were calling off and taking all the money they could get," she said. "We called the agencies in and told them that we expected them to have their employees meet hospital standards just like everybody else and that the money needed to be spread around the hospital more evenly."

Phillips said she terminated agencies that didn't comply and hired more in-house hospital staff. Phillips also organized one-on-one meetings and breakfast meetings with staff to hear concerns and to voice her own.

"We told them, we're not kidding — either you want to stay and follow the rules, or go," she said.

Krasker and other consultants attempted to head off criticism by meeting regularly with city officials and by holding frequent news conferences.

"You identify ahead of time those who are going to disagree with your decisions," Krasker said. "You try to judge the fallout and proactively include those parties. If people can understand every decision and move being made, people will get on board with tough decisions."

But critics of the hospital remain. Activist Vanessa Dickson believes Southeast is still providing substandard service to the community. She said the government needs to provide more resources to make it a truly first-rate hospital.

"Greater Southeast is the only hospital on this side of town, and it's a death trap," she said. "It is the appearance of public healthcare in the absence of a public hospital…. It's a scam, it's a con, it's all smoke and mirrors."

Bob Malson, the current president of the D.C. Hospital Assn., said Southeast is far from perfect. But he said he is heartened by the progress the hospital has made so far.

"It has come a long way," Malson said. "There is light at the end of the tunnel — it can be fixed, but you don't overcome years of mismanagement in a few weeks."

Phillips is also cautiously optimistic. "We're getting to where we need to be," she said.

But she stressed the road ahead won't be easy.

"A lot of our physicians are aging, and there's no succession plan," she said. Nurses are also hard to come by, she said. Before, people would come and see what it is like and then leave because the environment was too chaotic and stressful.

"I tell people that this is a place to come in and grow — this is an opportunity."